Presented by,Shandy Adamson
Identify seven reasons as to why
documentation is important
 Learn how to document properly
 Describe different document formats
 Learn how to document in different settings
and in challenging situations
 Explain the importance of documentation in
the court room
 Identify the advantages and disadvantages of
computerized documentation systems
 Identify how to save time when documenting

 Why
Documentation is Important?
 Coordination
of care
 Accreditation and licensing
 Performance improvement activities
 Peer review
 Requirements for reimbursement
 Legal protection
 Research and continuing education
Document accurately and objectively
 Get facts about situation before charting and
don’t make assumptions
 Document clearly and thoroughly
 Note times carefully
 Don’t use block charting that covers a wide
range of time
 Avoid assigning blame or calling attention to
errors

Avoid using terms associated with errors
 Fill out forms correctly, write in ink, sign
each entry
 Use standard abbreviations
 For drug names use generic rather than trade
names and spell drugs out correctly
 Write legibly and spell correctly
 Correct errors and omissions

Cosign correctly
 Use caution when you countersign a
subordinate’s chart entries
 Don’t document care given by someone else
 Follow correct procedures for late
documentation

 Documentation
 Narrative
formats
or source oriented charting
 Problem orientated charting
 Focus charting
 PIE charting
 Charting by exception
 Fact charting
 Core charting
Patient database
 Patient problem list
 Initial plan for each identified problem
 Progress notes
 Discharge summary

Acute care documentation
 Long term documentation
 Documentation in homecare

Patient must be confined to the home.
 Patient must need skilled services on an
intermittent basis.
 Care must be reasonable and medically
necessary.
 Patient must be under a physician’s care.

Refusal of treatment or failure to follow
restrictions
 Against medical advice
 Incident reports
 Advance directives
 Difficult patients
 How to document understaffing
 How to document negligent or unsafe
practice
 Physician orders
 Unlicensed assistive personnel

Laws and standards
 Legal basics
 Critical incidents


Advantages of computerized documentation
 Store
and retrieve information quickly, simply and
reliably
 Update information consistently and efficiently
 Link sources of patient information
 Use standardized terminology
 Promote communication among health care workers
 Facilitate transmission of request slips and patient
information between departments
 Protect patient confidentiality
 Provide legible and grammatically correct
documentation
 Contain valuable data on patient populations

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Disadvantages of computerized documentation
May scramble patient information if used
improperly
Can interfere with patient’s right to
confidentiality if security measures aren’t
followed
May break down which causes important
information to be temporarily unavailable
May be expensive
Can restrict the accuracy of information if the
computer restricts vocabulary or phrasing
Can increase documentation time if too few
terminals are available
 Save
time when you document
 Before
documentation: right patient medical
record and information
 Use nursing process to document
 Chart as soon as possible after you provide care
 Use flow sheets and bedside charting if possible
 Don’t repeat information
 Sign off with initials

Habel, M. (2014). Document It Right: A Nurse's Guide to Charting. .
Retrieved May 7, 2014, from
http://ce.nurse.com/RetailCourseView.aspx?CourseNumber=60076&page
=8&IsA=1